Select Committee on Health Minutes of Evidence

Memorandum by Professor John Yates



1.  There are two compelling reasons for re-examining the basis of the consultants' contract. Firstly, there has been a longstanding unresolved political dilemma—"Should consultants be paid a reasonable and comparatively high salary or does the NHS simply offer a less than adequate salary that can be supplemented by undertaking private practice both during the normal working week and out of hours?" Secondly, and probably consequential to the current arrangement, "Is there any link between the contract and the long and unfair waiting times experienced by many patients?" Patients contrast the longstanding political promise that offers access to health care determined by need rather than the ability to pay, with the reality that consistently flies in the face of the promise.

  2.  In one outpatient clinic this month a patient called Keith discovered that he required heart surgery. The surgeon explained that ideally the operation should be performed soon, but as his condition was not urgent he would have to wait about nine months. For a payment of £10,000 the same surgeon would operate on him within two weeks in the same NHS hospital or in a private hospital in a neighbouring city some 25 miles away. His position is not an isolated example. A telephone call to the College of Health Helpline revealed that no shorter waiting times for routine patients were available anywhere else in England for the type of heart surgery that Keith requires.

  3.  The health care system in this country will consistently allow other patients to be treated before Keith. They will be operated on by NHS surgeons, both in NHS hospitals and private hospitals, even though their need is not greater. In the NHS hospital that Keith is waiting to enter, one cardiac patient in every 20 is a private patient. This means that Keith will probably be overtaken by 45 private patients in nine months in that hospital. Their operations will be performed by NHS surgeons in NHS theatres supported by expensive intensive care facilities and staff. Their earlier access to care will simply be based on their ability to pay.

  4.  The extent to which the consultants' contractual conditions contribute to this inequity is uncertain. It is fairly clear that long waiting times are not solely caused by this issue and that resource shortages, boundary definition and inefficiency are very significant joint causes. The consultants' contract may be one associated factor. The consultants' contract may, on the other hand, be seen as a major cause of inequitable waiting. Queue jumping is really only possible where payment is made to surgeons.

  5.  The fact is that despite successive calls for clarity regarding the interface between the NHS and the private sector we still know far too little about the apportionment of consultant workload and time between the NHS and the private sector.


  6.  Throughout the history of the NHS politicians, regardless of political affinity, have emphasised its high ideals. Their aspirations are for a comprehensive and fair service yet, despite 50 years of a nationalised service, waiting times are long and unfair. Aneurin Bevan, Winston Churchill, Margaret Thatcher and Tony Blair have all reassured the public that access to health care will be dependent on need and not on the ability to pay. Their rhetoric is not matched by either policy or practice. This section examines the policy setting and suggests that there are two areas where aspiration and policy cannot be squared. Firstly, from the inception of the NHS, its hospitals have made facilities and staff available for the treatment of private patients. Secondly, the NHS permits its key personnel to treat private patients whilst at the same time exercising no control over the balance of activity between the two sectors.

 (a)   A two-tier NHS

  7.  The opening paragraph of the 1946 National Health Service Act states that, "It shall be the duty of the Minister of Health to promote the establishment in England and Wales of a comprehensive health service." The next paragraph commences with the self-contradictory statement that: "The services so provided shall be free of charge, except where any provision of this Act expressly provides for the making and recovery of charges." The NHS itself offers a free service for which some patients are allowed to pay. Since its inception it has always had private facilities and allowed its surgeons to operate on private patients in NHS hospitals. It is argued that these are additional facilities and ultimately save the NHS time and money in not having to treat patients who would otherwise depend on the NHS. The contrary view is that the capital stock of facilities within NHS hospitals has not been funded by the private sector and is not built into charges; that training costs are not included; and that there is a constant abuse of the dual system, with private patients being treated on NHS operating lists.

  8.  According to Williams, [1] "In 1986, partly to allay concerns about unjustifiable priority being given to private patients, the Government published a set of principles to guide their management [2] which specified that accommodation and services for private patients should not significantly prejudice those for NHS patients; earlier private consultation should not lead to earlier NHS admission nor access to earlier diagnostic procedures. . ." Subsequently the NHS and Community Services Act of 1990 [3] re-affirmed that hospitals could provide private patient accommodation, but with the proviso that NHS contractual obligations were fulfilled.

 (b)   Serving two masters

  9.  Since the establishment of the NHS consultants have been permitted to work both in the NHS and the private sector. Throughout most of the history of the NHS there has been a nominal curb on private practice in the sense that full-time consultants were not allowed to undertake private practice, above a minimal amount, without reducing their NHS pay by one-eleventh. For consultants on ten-elevenths contracts there is no limit to the amount of private practice that they can undertake. In recent years the loss of central control over contractual arrangements has led to some Trusts relaxing these regulations and in some locations it is now possible for full-time consultants to undertake private practice without restriction.

  10.  These various contractual arrangements place consultants in the invidious position where there is a conflict of interest. Such conflicts of interest are actively avoided in both commerce and the public sector. No electricity company official would expect to retain his employment if he offered to replace electricity meters in the evening, as a private arrangement, for an additional cash payment, in the event of the company being unable to change the meter as quickly as the customer would like. As one consultant neurosurgeon said in response to the patient asking whether his BUPA insurance would speed up treatment. "Would the patient be so casual in offering a bribe if he was speaking to a police officer instead of an NHS consultant?" [4]

  11.  Long waiting times are caused by many factors, including a shortage of resources, inefficiency, and a lack of clarity over the decision criteria regarding referral and admission. Not all of these issues are within the control of consultants, but in some areas of efficiency and decision-making they have key responsibility and there is a potential conflict of interest or, as one commentator put it "An invitation to mischief". [5]

  12.  Policy in this country is unclear. If the failure to match aspiration with policy is accidental, there ought to be the will to change the policy. If the failure is deliberate then the system might be considered as morally corrupting.


  13.  In the absence of detailed analysis of the division of work and time spent in the two sectors, this section tries to piece together some of the evidence already available. It examines the differences in waiting times and the division of workload, time and income between the two sectors. It needs to be set against the back-cloth that the contractual position for the majority of consultants (particularly in surgery and anaesthetics) is based on the maximum part-time contract. This requires consultants to "devote substantially the whole of their time to hospital work and to give it priority on all occasions". [6] It also has to be set against the fact that the reduction of one-elevenths of the salary would imply a division of time which is 9 per cent to the private sector and 91 per cent to the NHS.

  14.  The evidence presented is almost exclusively concerned with the work of surgeons. Their immediate clinical workload includes sessions in operating theatres, outpatient clinics and ward rounds, but their overall duties and responsibilities are much greater than these three items. They work as part of a large team and the way in which work is divided differs between individuals and specialties. Some of their responsibilities are not directly clinical, but are activities such as teaching and research. These overlap with their clinical duties and in consequence are difficult to identify easily.

 (a)   Evidence about different waiting times

  15.  Waiting times for an outpatient appointment and inpatient treatment vary hugely from town to town, specialty to specialty, and consultant to consultant across the country. One consistent feature about waiting times however, is that those patients who are prepared to pay are treated much more quickly than those who wait their turn in the NHS. The following are examples.

  16.  Comparisons between NHS outpatient waiting times and private sector rooms times were made for orthopaedics and ophthalmology in 1994. Waiting times for all English NHS clinics averaged 25 weeks for orthopaedics and 19 weeks for ophthalmology. In the private sector, sample waiting times averaged two weeks in both specialties. [7]

  17.  Waiting times for inpatient and day case admission are consistently shorter for private patients, even within NHS hospitals. Williams [1] examined waiting times over the six year period from 1989-90 to 1994-95. He found that median waiting times for NHS patients rose from 32 to 42 days, whilst for private patients it fell from 11 to nine days. For some operations the contrasts were enormous. In the case of ophthalmic surgery for prosthesis of lens NHS waiting times averaged 175 days, but for private patients 13 days. One of his conclusions was that, "In 1994-95, private patients were admitted sooner than others for operations for potentially serious conditions, and much sooner for less urgent procedures."

  18.  It is incontrovertible that private patients are treated more quickly than NHS patients for similar conditions. There is also some evidence which suggests that not only do the rich get treated earlier, but also more often. It is possible that their easier access might also result in a higher rate of treatment and one which is not matched to need. Access to cardiac surgery may be greater for patients in high social classes, whereas need is greatest in the lower social classes. [8]

 (b)   Comparisons of workload

  19.  A simple comparison of NHS and private elective inpatient and day case treatment shows that the NHS has 4,349,722 admissions per year compared with 739,810 in the private sector. [9] The private sector thus undertakes 14.5 per cent of the total elective volume. The proportion for planned surgical operations is 13.4 per cent and these figures have remained fairly constant since 1981. [10] The latest figures for some of the more common operations are shown in the Table below.

Private Sector
Private Sector
of Total

Cataract & lens
Tonsillectomy &
Drainage of middle ear
Operations on coronary arteries
Abdominal hernia repair
Total hip replacement

Source: Williams et al, 2000 [9].

  20.  This division of activity does not reflect the true split of consultant workload between the NHS and the private sector. In the NHS, whilst the work of junior surgeons is directly or indirectly supervised by consultants, the actual number of operations that consultants personally perform, or assist with, is commonly regarded as something under 50 per cent of the total number of procedures.

  21.  Within NHS hospitals private patients are operated on, almost without exception, by consultants. Some are accused of giving undue emphasis to their private work in the NHS, but there is no systematic evidence of this. Illustrations of imbalance come from NHS staff. One junior anaesthetist cited his experience of the behaviour of a consultant in the 1980s—"This surgeon had two or three NHS operating sessions per week and a healthy private practice. He took about two hours to perform a total hip replacement and consequently most sessions consisted of one total hip and a variety of shorter operations. However, he used to bring his private total hip replacement patients into the NHS hospital for operations and then transferred then after a day or so to the private hospital. A large proportion of the total hip cases operated on at the NHS hospital were private. You will already have realised that this enabled the surgeon to operate on many more private patients (as he also operated at the private hospital) whilst simultaneously extending his already long NHS waiting list for total hips. [11] My studies of one ophthalmologist's work at a specialist eye hospital showed that of the 178 operations he personally performed in one year, in his one NHS operating list per week at that hospital, 96 were on private patients. These examples, however, are anecdotal and certainly not representative of all surgeons.

  22.  A more systematic attempt was made to study the private practice and NHS activity of cardiac surgeons in London based on three studies that used 1992-93 data for all coronary artery bypass graft (CABG) operations performed inside the M25 ring. In that year 10,788 CABG operations were performed, of which approximately 4,375 (40 per cent) were on private patients. Of the private patients, 2,480 came from abroad. On the basis of the data generated from the three studies [12, 13, 14] it was calculated that 60 per cent of consultant operations were performed on private patients. [7] The figure for one individual was claimed to be as high as 80 per cent. Other examples include:

  23.  A specialist orthopaedic hospital performed 1,263 orthopaedic and trauma operations in a three month period. 735 were performed by consultants, of which 321 were on private patients. 25 per cent of the NHS hospital's operations were on private patients and 44 per cent of consultants' operations were on private patients.

  24.  A specialist medical oncology hospital with 14,000 first outpatient attendances per annum for NHS patients had over 12,000 first and subsequent private patient attendances in the same year.

  25.  Over a six year period one specialist cardiac unit saw six private outpatients for every 10 new NHS patients.

  26.  There is evidence that some consultants devote a disproportionate amount of their attention to private patients. Individual examples suggest that for some the clinical workload, as measured by patients seen or treated, might result in private activity being between 10 per cent and 40 per cent of total volume for a substantial number of consultant surgeons. However, the evidence is not systematically gathered and it does not take account of indirect activities such as teaching, research, management, on-call duties, etc.

 (c)   Estimates of time spent in the two sectors

  27.  Information on the division of time between the two sectors is restricted to self-reported surveys and investigative studies of private sector activity. The self-reported studies undertaken for the Monopolies and Mergers Commission [15] in 1992 reported an average 62 hour working week, of which 11 hours were spent in the private sector. The study covered just under 3 per cent of the consultant workforce, but did not provide separate data specialty by specialty.

  28.  A more recent confidential study of the workload of 704 consultant surgeons reported that 34 per cent worked over 48 hours per week on NHS duties, excluding on-call commitments. [16] The MMC study did not specify what proportion of the hours spent in the private sector were hours in the normal working week, but there is evidence that a substantial proportion is spent during working hours, 9.00 am to 5.00 pm, Monday to Friday. The Norwich Union study of operating in private hospitals [17] showed that 72 per cent of operating took place during normal working hours. Studies of private rooms availability [7,18] demonstrated that the vast majority of rooms sessions (82-94 per cent) were in normal working hours.

  29.  These studies showed that the average number of rooms sessions per week was 1.7, suggesting 5.5 to 6.0 hours per week set aside for that activity. 36 per cent of consultants had one rooms session per week, 38 per cent had two sessions per week and 18 per cent three or more.


No of Consultants
Av No of Private Rooms Sessions

T&O [7]
Ophthalmology [7]
ENT [19]
ENT [19]

  30.  Studies of overall time spent in the private sector have proved difficult to undertake. In 1998, Health Which? selected a sample of 60 NHS consultants equally divided between ENT, Ophthalmology and Orthopaedic surgery. In each specialty, 10 consultants were selected with some of the longest and shortest waiting lists in the country. Researchers posing as the relative of a patient enquired which days were available for a private consultation and which days were set aside for private operations. They found that on average consultants set aside over two half-days per week for private consultations and operations. [18]

  31.  In a study of consultant workloads in Trauma and Orthopaedics [20] consultants were divided into three groups of low, medium and high workload, based on admission numbers. At interview, 29 consultants responded to questions about the level of private sector activity in the working day. The low, medium and high groups had average figures of 0.9, 1.2 and 1.9 sessions per week in the private sector. An independent check of these results was attempted by a telephone enquiry to every surgeon's secretary. In this case, rooms availability alone was given as 0.8, 0.8 and 1.5 sessions per week. The survey was extended to a further 29 (non-interviewees) and for similar low, medium and high workload consultants rooms availability averaged 1.6, 1.4 and 1.3 rooms sessions per week. The results of the survey showed that most surgeons spent at least one half day per week in the private sector, a substantial number spent a day a week in the private sector and for a small number a higher figure still.

  32.  Job plans and consultant timetables rarely make any reference to sessional commitments in the private sector. In a study of 109 orthopaedic surgeons' operating times in one region, private practice information was only recorded on the job plans and timetables of 14 of the consultant surgeons. The average number of sessions per week allocated to the private sector was 1.9. Four were scheduled to work for 1.5 sessions per week, nine for 2.0 sessions a week and one for 3.0 sessions a week. There is no way of knowing from these timetables what actual amount of time was spent in the private sector and whether it was less or more than the figures cited.

  33.  A number of confidential studies have been undertaken because of concerns about certain consultants' commitment to the NHS. In the 19 cases studied, in five surgical specialties, the consultants concerned averaged three half-day sessions per week in the private sector, and seven of them spent four or more sessions per week in the private sector, all of whom had maximum part-time contracts.

  34.  Combining the evidence from various studies [21,22,15,17,23,7] it appears that about 70 per cent of private practice work is done during the working week. This represents eight hours, or one full working day, out of the prime time of the 35 hour working week (see Table 1 and Figure 1 in Appendix). Given the evidence available from the Audit Commission's studies of clinic activities in theatres and outpatient clinics, we are left with the conclusion that large volumes of non-clinical NHS activity takes place outside normal working hours. It must be doubtful whether this is the right time for audit, teaching, administration, research and clinical governance.

  35.  The lack of objective evidence about the split in time between the two sectors is all the more worrying when one examines the evidence about the operating of Trauma and Orthopaedic surgeons. This group of consultants, faced with the largest and longest waiting lists in the UK, are reduced to an average operating time per week of just seven hours (excluding anaesthetic time). [24] This data, too often seen as an attack on consultants, is an indictment of the NHS that fails to use its surgeons effectively. As the President of the British Orthopaedic Association said, "Most surgeons would prefer to operate for a minimum of 12 hours a week—surgeons enjoy operating". [25] Given such low levels of operating, the time has come to examine how the other 50 hours per week are spent, be they in the NHS or the private sector.

 (d)   Evidence about the split of income

  36.  In 1997-98, over 50 NHS Trusts each had a private sector income that exceeded £1 million per annum. [26] In some cases the level of income is substantial in proportion to the NHS budget and risks skewing the priorities of the hospital when negotiating its workload. This can be particularly the case for single specialty hospitals and regional centres.

  37.  Studies of consultants' earnings have been made by the Monopolies and Mergers Commission in 1992 and by the Inland Revenue in 1986-97, 1991-92 and 1993-94. NHS earnings are basically the same regardless of specialty and differ between consultants only on the basis of years in post and the level of merit award payments. Private sector income varies depending on the level of demand and the time each consultant is prepared to devote to private work. There is consistent evidence that some specialties have a greater level of earnings than others. [15] In particular, surgical specialists and anaesthetists tend to earn more than medical specialists. The higher earners are mostly to be found amongst the 5,000 or so consultant surgeons and 1,000 anaesthetists rather than the remaining 15,000 consultants.

  38.  The Inland Revenue studies of all consultants' earnings revealed that by 1993-94, 49 per cent of maximum part-time consultants' earnings was from private practice. This means that for the majority of surgeons and anaesthetists much more than half of their income is generated from the private sector. This evidence can be used to support the argument that NHS salary levels are too low.

  39.  Those figures suggest that surgeons have little financial incentive to work in the NHS. An NHS post is merely needed to generate private work and to provide a pensionable base. The financial dilemma faced by consultants is illustrated by conversations with three surgeons in recent months. The first was a consultant who does no private practice but merely does medico-legal work on Saturday mornings. This work alone enables him to double his NHS salary. The second example is a surgeon who operates on three mornings per week and has three afternoon clinics per week in the NHS. In the remaining two days he undertakes private work for which he earns £3,000 a day. He explained to me that he was reluctant to undertake a further NHS operating list but would be prepared to do so if the NHS would pay him an additional £1,500 per half day. The third discussion was with a consultant cardiac surgeon in London regarding the suggestion that private work should be separated from the NHS and that consultants should be required to work in either one sector or the other. He explained that, given an income of one third of a million pounds per annum from the private sector, it would not take him too long to make his decision about which sector to work in.

  40.  The division of earnings between the NHS and the private sector for the average consultant is split 50:50, but for surgeons the proportion is generally much higher in terms of earnings from the private sector.

  To summarise the evidence, we find:

  41.  waiting times for private patients are always shorter than for NHS patients;

  42.  the consultants' contract requires them to devote substantially the whole of their time to the NHS and possibly implies that no more than 10 per cent of working time should be devoted to the private sector;

  43.  work activity as measured by operations performed suggests that 10-40 per cent of the workload is committed to private practice;

  44.  estimates of time devoted to the private sector suggests that 20 per cent of the normal working week is devoted to the private sector;

  45.  earnings data shows that at least 50 per cent of earnings comes from the private sector for the average consultant, and that for surgeons this figure is considerably higher.

  46.  The current division of activity and time is highly likely to be influenced by the perverse incentive of financial reward being much greater for one sector than the other. This places an enormous and almost immoral pressure on consultants and their families.


  47.  There is considerable timidity in approaching this sensitive issue. Successive governments and the Department of Health have consistently evaded calls to study the interface between the NHS and the private sector.

  48.  In 1990 the Public Accounts Committee tried to ascertain how much time it would be reasonable for a consultant to take off from the NHS in order to undertake private practice and in its formal report stated, "We believe that health authorities need a more accurate picture of the total level of consultants' commitments to ensure that their responsibilities for the treatment of patients are not put in jeopardy through working excessive hours. [27]

  49.  In the following year the House of Commons Health Committee recommended, ". . . that the Department of Health carry out a study . . . to try and determine the influence, either positive or negative, that private practice in the same unit or specialty has on the waiting list and waiting time for treatment. The results of such a survey should help inform districts in their local discussions of consultants' job plans". [28] In the same year the Welsh Affairs Committee of the House of Commons concluded, "We agree with the Health Committee that the influence of private practice be examined". [29]

  50.  In 1995 the Labour Party set out its agenda for a healthier Britain and commented, "Private medicine has come to play an increasing role as the government has sought steadily to erode the NHS. The balance between public and private medical provision is one that has to be examined carefully to ensure that the use of NHS premises and resources is adequately recompensed and that there are no consequential adverse impacts on waiting times for NHS patients. The government has ignored the recommendations of the House of Commons Health Select Committee in 1991 that, `the Department of Health carry out a study to try and determine the influence, either positive or negative, that private practice in the same unit or specialty has on the waiting list and waiting time for treatment'. Labour will act on this recommendation". [30] It has not yet done so, despite a further call from the Independent Inquiry into Inequalities in Health [31] which recommended establishing a review of the relationship of private practice to the NHS with particular reference to access to effective treatments, resource allocation and availability of staff.

  51.  A decade ago it was argued that the uncertainty around this issue would be clarified through the introduction of "job plans" for consultants. In fact, the job plans have made little difference to the inequity that exists as far as patients are concerned. Since their introduction it has become commonplace to see Trusts accepting that consultants should spend two half days a week in the private sector, whereas prior to their introduction one session per week was the norm. We must be careful to ensure that the optimistic claims about the value of job plans are not repeated with vague promises about the potential impact of the re-negotiation of consultants' contracts. If this nation wants access to hospital care to be available on the basis of need, it has to wholeheartedly address the loosely worded legislation of 1946 and the political fudge surrounding the consultants' contract. Both provide a conflict of interests that patients find unacceptable. As the Secretary of State said on 18 May this year, "There will be tough decisions to be made, decades-old shibboleths to be laid, it will require the courage to change by members of the Government as much as members of the Royal Colleges". [32]


  52.  Two of the possible reactions to this paper are either that more evidence is required, or that action is required to remove the conflict of interests that is associated with inequitable waiting times. If further evidence is required this cannot simply be based on the opinions of politicians, civil servants, managers, surgeons and patients. It requires the gathering of detailed data about the patients treated in both sectors. The data needs to be linked together at consultant level and ought to be collected for a minimum period of three months, preferably for a full year. Any prospective study should be matched by a retrospective analysis of data to ensure that the prospective study was reasonably representative.

  53.  If it is thought that action is required the two most obvious solutions are either to completely separate NHS and private sector activity, not allowing consultants to work in the two sectors simultaneously, or alternatively to exercise tighter and more systematic control on private sector activity within the NHS.

  54.  The case for suggesting a complete separation of private and NHS work is in part based on the fact that today consultants face an increasing level of pressure of the sort never experienced before. The demands of an ageing population, the reduction in junior working hours and increased responsibilities for clinical governance add pressure to the demands of research, teaching, audit and clinical work. This is not work that should be squeezed into evenings and weekends and four or so half-day sessions competing with the demands of on-call commitments and time spent in the private sector. It is a job that demands highly skilled professionals and requires their full attention. They should not be forced to divert their attention to the private sector simply to increase their income to a reasonable level. By most standards the basic consultant pay must be seen as unreasonably low. The financial position now facing the NHS gives an opportunity to increase the take-home pay of consultant surgeons and anaesthetists. Such a solution will not be easily negotiated for those consultants whose income outside the NHS adds £100,000 or more to their annual income. The process could, however, be staged and increasingly reward those who devote the whole of their time to the NHS.

  55.  A second course of action would be to exercise extremely tight control on private sector activity within the NHS that guarantees private patients are not treated earlier than NHS patients. Guidelines could be introduced that would not permit hospitals or surgeons to undertake private practice unless outpatient waiting times were less than four weeks for routine appointments, all inpatients were treated within three months, and that certain minimum workload standards were attained.

  56.  The results of such changes should be measured in terms of improved equity of access and not in terms of changes in levels or distribution of activity. Patients want a fair National Health Service, where they can receive care on the basis of need rather than the ability to pay. Any actions taken should be measured against that criterion.

5 June 2000


  1.  Williams, B (1997). Utilisation of National Health Service hospitals in England by private patients 1989-95. Health Trends, 29 (1): 21-25.

  2.  Department of Health and Social Security (1986). Health services management: private practice in health service hospitals. London, Department of Health and Social Security. Health Circular HC(86)4.

  3.  National Health Service and Community Care Act 1990. London, HMSO.

  4.  Curry, D (1996). BUPA subscription? That will do nicely. British Medical Journal: 313: 431.

  5.  Light D (2000). The two-tier syndrome behind waiting lists. British Medical Journal; 320: 1349.

  6.  DHSS (1979). Pay and conditions of service: contracts of consultants and other senior hospital medical and dental staff. Personnel Memorandum PM(79)11, Annex "A": The whole time/maximum part-time option.

  7.  Yates, J (1995). Private eye, heart and hip: surgical consultants, the National Health Service and private medicine. London, Churchill Livingstone.

  8.  Ben-Shlomo, Y and Chaturvedi, N (1995). Assessing equity in access to health care provision in the UK: does where you live affect your chances of getting a coronary artery bypass graft? Journal of Epidemiology and Community Health; 49: 200-204.

  9.  Williams, B, Whatmough, P, McGill, J and Rushton, L (2000). Private funding of elective hospital treatment in England and Wales, 1997-98: national survey. British Medical Journal; 320: 904-5.

  10.  Nicholl, JP, Beeby, NR and Williams, BT (1989). The role of the private sector in elective surgery in England and Wales, 1986. British Medical Journal; 298: 243-7.

  11.  Personal communication to author, 2000.

  12.  London Implementation Group (1993). Report of the Cardiac Specialty Review Group. London, HMSO.

  13.  Williams, BT and Nicholl, JP (1994). Patient characteristics and clinical caseload of short stay independent hospitals in England and Wales 1992-93. British Medical Journal; 308: 1699-1701.

  14.  IACC (1993). Observations on the workload of consultant surgeons. Unpublished confidential report to the Chairman and Co-ordinator of the Cardiac Specialty Review Group.

  15.  Monopolies and Mergers Commission (1994). Private Medical Services: a report on agreements and practices relating to charges for the supply of private medical services by NHS consultants. London, HMSO.

  16.  Lane, R and Reeves, B (1999). Consultant workload: a report of a confidential enquiry 1999. London, Association of Surgeons of Great Britain and Ireland.

  17.  UK Specialists' Fees—is the price right? 1992; Eastleigh, Norwich Union Healthcare.

  18.  A very private practice. Health Which? December 1998, p 16.

  19.  Harley M, Jayes, B and Yates, J (1999). Long and Short Waiting Times in ENT. A report commissioned by the Department of Health. Birmingham, University of Birmingham. Inter-Authority Comparisons & Consultancy.

  20.  Harley, MJ and Yates, JM (1998). Consultant workload in Trauma and Orthopaedics. A report for the Department of Health. Birmingham, University of Birmingham. Inter-Authority Comparisons & Consultancy.

  21.  Audit Commission (1995). The doctors' tale: the work of hospital doctors in England and Wales. London, HMSO.

  22.  Audit Commission (1996). The doctors' tale continued: the audits of hospital medical staffing. London, HMSO.

  23.  Laing's Healthcare Market Review 1999-2000; pp 81-83. London, Laing & Buisson Ltd.

  24.  Harley, M, Jayes, R and Yates, J (2000). The allocation and use of Trauma & Orthopaedic Operating Theatres in Two English Regions. Birmingham, IACC, Health Services Management Centre, University of Birmingham.

  25.  Phillips, H (2000). Held back by woeful lack of resources. Health Service Journal; 18 May: p 23 (Letter).

  26.  The Fitzhugh Directory of Independent Healthcare and Long Term Care: Financial Information 1999-2000. London, Health Care Information Services.

  27.  House of Commons, Committee of Public Accounts (1990). The NHS and Independent Hospitals. Twenty-eighth Report. London, HMSO.

  28.  House of Commons, Health Committee (1991). Public Expenditure on Health Services: Waiting Lists. First Report. London, HMSO.

  29.  House of Commons, Welsh Affairs Committee (1991). Elective Surgery, Volume 1, Sixth Report. London, HMSO.

  30.  The Labour Party (1995). Renewing the NHS: Labour's agenda for a healthier Britain. London, The Labour Party.

  31.  Acheson, D (Chairman) (1998). Independent Inquiry into inequalities in health. London, The Stationery Office.

  32.  Baldwin, T (2000). Consultants' pay structure "key factors in waiting lists". The Times; 19 May: p 4.

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